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Revista Interamericana de Psicologia/Interamerican Journal of Psychology - 2004, Vol. 38, Num. 1 pp. 113-118 A Case Study Illustrating the Interplay Between
Psychological and Somatic Dissociation
Alfonso Martínez-Taboas 1
Universidad Carlos Albizu, Puerto Rico Abstract
The concept of Dissociation was originally conceived as having a psychological and a somatic component.
Nevertheless, recent versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
have isolated both elements. In the DSM the psychological manifestation of dissociation is diagnosed as a
Dissociative Disorder and the somatic domain is diagnosed as a Somatoform Disorder. However, recent
empirical and clinical evidence have been highlighting and corroborating a high degree of comorbidity between
such disorders and a constant interplay between somatic and psychological dissociation. In the following case
study, the clinical constellation of the patient nicely illustrates that her dissociative defenses began as a Conversion
Disorder and how, after a mishandling of the case by a clinician, her dissociation symptoms were instantly
transformed in a typical Dissociative Amnesia Disorder. Cases like this convincingly illustrate how the dissociative
defenses not only subsume the mental but also extend to the bodily domain.
Keywords: Psychopathology; conversion disorder; dissociative disorder; psychogenic amnesia.
Estudio de Caso Ilustrativo de la Interrelación entre la Disociación Psicológica y la Somática
Compendio
El concepto de Disociación originalmente incluía componentes psicológicos y somáticos. Sin embargo, versionesrecientes del Manual de Diagnóstico y Estadísticas de los Trastornos Mentales (DSM-IV) han deslindadoambos elementos. En el DSM las manifestaciones psicológicas de la disociación se identifican comomanifestaciones de un Trastorno Disociativo; mientras que el aspecto somático se identifica como parte de losTrastornos Somatoformes. Sin embargo, en estudios clínicos recientes se ha resaltado el hecho de que hay unacomorbilidad extrema entre ambos trastornos y que se puede corroborar el hecho de que hay una interdependenciaentre las manifestaciones psicológicas y somáticas de la disociación. En el siguiente estudio de caso, laconstelación clínica de la paciente ilustra de una manera lúcida cómo sus defensas disociativas comenzaroncon la manifestación de un Trastorno Conversivo y, tras un mal manejo clínico, sus síntomas disociativos deinmediato se transformaron en un Trastorno de Amnesia Disociativa. Casos como estos muestranconvincentemente cómo las defensas disociativas no sólo incluyen el aspecto psicológico, sino que también seextienden al dominio corporal.
Palabras clave: Psicopatología; trastorno conversivo; trastorno disociativo; amnesia psicógena.
When in the 19th century Pierre Janet (1859-1947) with the Somatoform Disorders. Subsequent editions of formulated his ideas about the specific components of the DSM-III-R (American Psychiatric Association, 1987) dissociation, he clearly included the presence of both and the DSM-IV (American Psychiatric Association, psychological and somatoform dissociative phenomena 1994) have retained that division. This decision has been (van der Hart & Friedman, 1989). Such symptoms as amply rejected or questioned (Cardeña & Spiegel, 1996; anesthesia, analgesia, and loss of control over motor Kihlstrom, 1994; Nemiah, 1991; Nijenhuis et al., 1998; responses were eloquent examples of what today some researchers call “somatoform dissociation” (Nijenhuis, First, there is extensive documentation that dissociative 2000; Nijenhuis, Spinhoven, van Dyck, van der Hart & patients report a wide array of somatic and conversion Vanderlinden, 1996, 1998; Sar, Kundakci, Kiziltan, Bakin, reactions (Boon & Draijer, 1991; Martínez-Taboas, 1991; & Bozkurt, 2000). Nevertheless, the members of the Task Ross, Fast, Anderson, Auty & Todd, 1990; Saxe, et al., Force of the DSM-III (American Psychiatric 1994). For example, Saxe et al. (1994) compared Association, 1980) decided to separate the motor/ somatization in dissociative and nondissociative patients.
somatic component of dissociation and to categorize it They found that 64% of the first group met the criteria fora Somatization Disorder, whereas none of the comparisonpatients met criteria for a Somatoform Disorder. For his 1 Adress: Vía del Parque St., #151, Parque del Río, Trujillo Alto, Puerto part, Pribor, Yutzy, Dean and Wetzel (1993) found that Rico. 00976. E-mail: AMartinez@albizu.edu women with high dissociation scores also reported many somatic symptoms, specially if there was a history of abu- The parents have never separated. According to the parents, se. In this context, the research by Nijenhuis, et al. (1996, from childhood until last year (1992) she was considered 1998) is highly relevant. Using the Somatoform a leader in her school, and she had always demonstrated Dissociation Questionnaire, which evaluates the severity excellent academic progress (all her grades were A’s).
of somatoform dissociative phenomena, the authors have Isabel and her parents denied any history of sexual or documented that dissociative disorder patients can be clinically differentiated from patients without a At the beginning of 1993 she had a car accident without dissociative disorder. The sensitivity of the scale is 94% any obvious health repercussions. On July 11 of 1993, when and the specificity is 98%. Such results corroborate the she was participating at a Catholic mass, she suddenly began clinical observation that dissociative disorder patients tend to feel dizzy and fainted. Six days later she began to to suffer from a wide range of somatoform symptoms.
experience recurrent and extreme headaches, dizziness and Secondly, many patients with DSM-IV Conversion a strange weakness in her lower extremities. When she Disorder present the clinical configuration of a dissociative was taken to the emergency room of an hospital, she had disorder. As an example, Kuyk, van Dyck and Spinhoven bradycardia (a slow heartbeat rate) and was given atropine.
(1996) and Bowman and Markand (1996) have documented She also had slight arrhythmia. A week later, she could not that more than 60% of pseudoseizure patients present a experience any sensations in her legs and could not move dissociative disorder. The fact that hypnosis is a very useful them. As a result, she was taken to three different hospitals clinical tool in the differential diagnosis of such seizures in Puerto Rico and was examined by endocrinologists, is another line of evidence in favor of the construct of cardiologists and various neurologists. She was submitted somatoform dissociation (Kuyk, et al, 1995; Kuyk, to many medical tests, including EKG, EEG, MRI, lumbar Spinhoven & van Dyck, 1999; Martínez-Taboas, 2002).
puncture, blood tests, among others. The results were all The decision to separate the somatic component of negative; the doctors could not find a specific cause for dissociation has been described by Cardeña and Spiegel as the paralysis. As a result of this, some doctors in Puerto «more a classification fashion than an absolute distinction Rico convinced her father and mother to translate the child between the disorders» (1996, p. 239). In fact, outside to a well-known hospital in the United States to continue North America, researchers and clinicians using the the search for the etiology of her paralysis.
International Classification of Disease-10 (WHO, ICD- There she underwent a second round of specialized 10, 1993) may diagnose conversion reactions as a branch medical tests, some of them very painful. After a two week medical evaluation, the medical staff decided that Isabel’s In the following case study, I present a clear-cut clinical paralysis was not of organic origin. They called her parents situation where a female adolescent demonstrated an together and explained to them that the cause of her interplay of different dissociative phenomena. Her daughter’s symptoms was emotional, or a conversion configuration began with some classic somatoform symptom. One neurologist proposed to hypnotize Isabel symptoms and, then, in a sudden and unexpected way, to explore the meaning of her paralysis. Both parents changed her symptomatic profile to a psychological agreed. The neurologist and one of his assistants took Isabel dissociation. What is unique in this case is the exact timing to an office and were successful in creating an hypnotic of the alternation from the somatic to the mental trance. But, after about fifteen minutes, Isabel began to cry and to yell in a desperate way. After various minutes ofsilence, the neurologist invited her parents to enter the The Case of Isabel
office. To the surprise of all present, Isabel did notrecognize her parents nor anyone else. She began to say to her mother: “Please, lady, help me. This man (referring Isabel (a pseudonym) was a 15 year-old adolescent to the doctor) is very bad». When her father and mother female when she came to my office in 1993 for a tried to make her recognize them, she insisted that they psychological evaluation. She could be described as tall, were complete strangers to her. Also, she could not slim and fairly attractive. The case was referred by Dr. C- remember her name nor her identity. On the positive side, I., who was her psychiatrist. She remained cooperative all of those present noted that Isabel could, at last, slightly move her legs. In fact, four days later she regained complete Isabel is the oldest daughter of three children procreated movement of her legs. The neurologist told her parents by a married couple. The mother is a teacher at an that at the hypnotic session he had strongly commanded elementary school and the father is a prominent architect.
her to stand up and walk. He said that after a few hours A CASE STUDY ILLUSTRATING THE INTERPLAY BETWEEN PSYCHOLOGICAL AND SOMATIC DISSOCIATION she should regain her memory. But, after 48 hours, Isabel memory of such episodes. At other times, still during still could not remember anything about herself and her her crises, she called herself Anita and said she was a history. On August 20 and 22, and while still in the USA, little girl. As such crises were disturbing to her parents, she was taken to a clinical psychologist for a her first psychiatrist decided to put Isabel on a psychological evaluation. The results of this evaluation antipsychotic (Haldol) and an anticholinergic (Cogentin).
revealed that her memory presented signs of “amnestic When I decided to interview Isabel alone, she said episode, disorientation, her affect was somewhat flat.
that “I know that I am not me, but I do not know who I Her thinking processes were well organized and am”. She also said that “I do not care about my past or appeared free from any delusional or bizarre material”.
who I was”. She repeatedly said that she could not feel The psychologist noted that the only thing she vaguely any loving feelings toward her parents, specially because remembered was her name and her father and mother both of them were overprotective and restricting her identity. He diagnosed Isabel with Conversion Disorder, activities. She told me that she perceived her home as a single episode and Psychogenic Amnesia. She was cell and herself as a prisoner. However, she did not know transferred to Puerto Rico with a strong indication of how to tell her parents that she was so deeply dissatisfied because she did not trust them. She told me that one of From September through December 1993 she had her cousins had told her that before her Conversion been in psychiatric treatment with two psychiatrists. With Disorder, she was depressed because her parents did not the first one she had three weekly sessions of want her to be out at night with her friends and that she psychotherapy for two months. Isabel and her parents was very resentful toward them. When I inquired about decided to search for a second psychiatric opinion the name of Anita, she told me that Anita is a 15 year- because, allegedly, the psychiatrist hardly spoke during old girl who had always been her best friend. Contrary to the sessions and they did not notice any significant herself, Anita was described by Isabel as always happy, advances in Isabel. On November 1993 she began with with liberal parents and as someone who was enjoying her second psychiatrists (Dr. C-I). He also diagnosed a her life. At the time of the interview, she could move her The psychological evaluation consisted of the Dissociative Experiences Scale (DES), the Thematic When I performed her psychological evaluation, and Apperception Test (TAT), the Draw a Family Test, the after slightly more than three months after the hypnotic Incomplete Sentence Test, the Minnesota Multiphasic session, Isabel had recuperated some of her Personality Inventory (MMPI), the Draw a Person Test, autobiographical identity and memory. For example, she told me that many of her memories had returned veryslowly and mainly in the form of flashbacks. She had Results of Psychological Tests
already recognized her parents and her two brothers. Sheremarked that she had not lost her academic skills or The DES is a self-report instrument that quantitatively knowledge; only those aspects of her identity. In other measures dissociative symptoms and experiences words, her procedural (her skills and habits) and her (Bernstein & Putnam, 1986). A total score of 30 suggest semantic (conceptual and factual knowledge) memory were the presence of significant pathological dissociation. She unimpaired, but her episodic or autobiographical memory obtained a score of 38 on the DES, which suggest the was totally impaired. Such a finding is consistent with recent presence of marked dissociative symptoms. Specifically, research on dissociative amnesia (Schacter, 1996). She she had elevated scores (+80) on the following seven items: noted that when some of her former teachers or school 1) Some people find that they have no memory for friends visited her, she still had to pretend to know them,because she had trouble recognizing some of them.
some important events in their lives.
Isabel and her parents told me that in August, 2) Some people have the experience of looking in a September and October she had various episodes where mirror and not recognizing themselves.
she woke up at two or three in the morning in a 3) Some people sometimes have the experience of dissociative crisis. She began to yell, cry and was violent feeling that other people, objects, and the world around toward her parents. During such crises she repeatedly said that she wanted to leave. Such crises lasted about 4) Some people sometimes have the experience of one hour and were frequent. Afterwards she had no feeling that their body does not seem to belong to them.
5) Some people find that they sometimes sit staring she did not have any loving feelings toward her parents; off into space, thinking of nothing, and are not aware of that she detested their overprotection; that she was ashamed of their behavior; and that she was only happy when she 6) Some people sometimes find that in certain was outside her home. About her past, she wrote: “I could situations they are able to do things with amazing ease and not answer this because I have forgotten part of my life”. spontaneity that would usually be difficult for them.
About herself she said that “I hate to be what I am right 7) Some people sometimes find that they cannot now”; that she was sad nearly all the time and that she only remember whether they had done something of have just trusted her friend Anita. Also, Isabel evidenced a strong preoccupation with her physical appearance. She wrote that The TAT is a projective test in which the individual reveal she wanted to be a famous model, that her most important their attitudes, feelings, conflicts and personality wish was to have a perfect body, that she did not want to be characteristics by making up stories about a series of fat, that she was ashamed of her weight and that her principal relatively ambiguous pictures (Groth-Marnat, 1990). On weakness was her extreme preoccupation with her figure.
the TAT a peculiar thing occurred. After reacting to cards # The MMPI is a widely used self-report test used to 1, 14, 12M, 3BM, I showed card #13MF. Picture 13MF determine the individual’s personality profile as well asany tendency to lie or to fake the results (Greene, 1991).
presents a young man standing in the foreground with his On the MMPI, Isabel was characterized as a deeply head in his arms. In the background is a woman lying in dissatisfied person, with frequent lability in her moods and bed. The most frequent plots that patients generate center with recurrent somatic symptoms. She demonstrated a 3- on guilt induced by illicit sexual activity. It also usually 1 codetype, showing the classic conversion “I”, which provides information on the subject’s attitudes and feelings means that Isabel had rigid defenses and that many of her toward aggressive and sexual feelings. She began saying: efforts were ineffectively directed toward trying to ward “I see a man.” At that specific point, she had a mental off anxiety. Many clients with such a profile use somatic blackout or a discrete dissociative episode that lasted more symptoms to avoid thinking or dealing with psychological that a minute. As a result Isabel insisted that she did not problems. “When physical symptoms do appear, they are want to continue with the TAT. Isabel’s reaction is relatively restricted and specific both in location and nature, consistent with the idea of central and overwhelming frequently involving pain in the extremities or head” conflicts with her sexual feelings and/or experiences. I (Greene, 1991, p. 271). In addition there was evidence of should stress that, at least in my interview with her and her great conflict with her parents. “These clients are fighting parents, they all stated that there was no history of sexual against something which is usually some form of conflict abuse. Of course, the possibility is open to the reality of with authority figures” (Greene, 1991, p. 155).
such experiences, although they were not explicitly On the Draw A Person Test, Isabel drew a very little revealed during the psychological evaluation.
woman with her arms at the back. She mainly projected a The Draw a Family Test is a projective test where deep sense of interpersonal insecurity, sexual inadequacy, the individual depicts groups of significant people in his or her environment (Groth-Marnat, 1990). On the Draw a Lastly, the Bender-Gestalt is a test where the individual Family Test she drew her parents and her two brothers, but copies nine geometrical figures which form the basis to she did not draw herself. It is interesting to note that in her hypothesize on the presence of functional and organic previous evaluation with the psychologist in the USA, she disorders. Although in Isabel’s drawings there are no clear also did not drew herself in the Family Kinetic Drawing.
organic indicators, I found significant details that suggests This usually is encountered in persons who are deeply the presence of anxiety, depression, insecurity and self- dissatisfied with their family. Also, in the previous psychological evaluation all of her family members had Overall, Isabel demonstrated primitive and rigid their hands hidden behind their backs, which can be defenses, a tendency toward using somatic symptoms to interpreted as her perception that her family did not provide express her dissatisfaction, problems with authority her with support nor with a nurturing environment.
figures, a tendency toward experiencing many dissociative The Incomplete Sentences Test, is a projective test symptoms, and a confusion about her identity and self.
in which the individual is required to complete a variety of I should mention that after the psychological sentences. The responses may be analyzed for the evaluation I lost contact with Isabel. The exception was projection of unconscious themes (Groth-Marnat, 1990).
a phone call from her mother, five months after the On this test, Isabel once again demonstrated a deep evaluation, informing me that Isabel had recently been displeasure with her family environment. She said that A CASE STUDY ILLUSTRATING THE INTERPLAY BETWEEN PSYCHOLOGICAL AND SOMATIC DISSOCIATION Discussion
walk, without examining the context or meaning of her symptoms, he was creating the opportunity for the The case of Isabel presents some striking findings. First, substitution of one symptom for another. I should note we can clearly note the interplay between her conversion that even some eminent behavior therapists, who and dissociative symptoms. After manifesting a classic traditionally have disputed the idea of symptom pseudo-neurological conversion reaction, where she could substitution, had documented some remarkable cases of not move nor feel her lower extremities, she transformed symptom substitution in patients with Conversion her conflicts in a more psychological way, blocking her Disorder (Blanchard & Hersen, 1976).
identity and her sense of self completely. As is usually the This case also highlights the fact that the etiology of case in patients with Conversion Disorder, Isabel inscribed some dissociative disorders can not be accounted for by a her conflicts and impotence in her body in what she trauma model. In the case of Isabel there is no convincing perceived as an intolerable and coercive family evidence that she had been traumatized. Rather, her environment. Helene Cixous (quoted in Showalter, 1985, dissociative reactions and defenses appear to be a way that p. 161), says: “Silence, silence is the mark of hysteria. The she used to psychologically escape from an intolerable great hysterics have lost speech.their tongues are cut off family situation, where she was overwhelmed by her parents and what talks isn’t heard because it is the body that talks”.
exigencies and overprotection. An interesting clinical detail I agree with Kihlstrom (1994), Nemiah (1991), and is that when she had her dissociative crisis at night, she Nijenhuis (2000) when they criticize the DSM-IV for alleged to be Anita (Isabel’s best friend), who reportedly separating the somatic aspects of dissociation, creating the had liberal parents that allowed her to express her energies misleading impression that dissociation can affect only and interests without interference. So, through her memory and identity. As Kihlstrom (1994) puts it: “The dissociative regressions, she could fantasize that she was symptoms of the conversion disorders are not physical, but mental in nature. And they do not suggest physical The fact that in the follow-up period she recuperated disorder, but rather a disorder in consciousness” (p. 387).
her identity, but began to manifest an eating disorder, is According to the research of Nijenhuis, et al. (1996), the also consonant with some literature that suggests a link frequent somatic and conversion symptoms of dissociative between some types of eating disorders and dissociation patients are a reflection of what they call “somatoform (Chandarana & Malla, 1989; Demitrack, Putnam, dissociative phenomena”. This posture is consonant with Brewerton, Brandt & Gold, 1990; Rodin, et al. 1998; the ideas of Pierre Janet, when he stated that dissociation Vanderlinden & Vandereycken, 1997). In the case of Isabel pertains to both psychological and somatoform I am tempted to speculate that as her dissociative defenses eroded, they were substituted by an obsession with her Although some authors have documented that body. By this means she could divert her deep dissatisfaction dissociative disorder patients present a comorbidity with with her parents and her life circumstances, and transform the somatoform disorders (Nijenhuis, 2000; Rodin, de them into another type of aversion: her sexuality and her Groot & Spivak, 1998; Sar, et al., 2000; Saxe, et al., 1994), the case of Isabel is striking in the sense that her dissociative Isabel’s previous psychotherapeutic approach have been defenses began as a somatoform manifestation, but ineffective, mainly because the psychiatrist adopted a subsequently were substituted and transformed to passive stance, which did not enhance her capacities to dissociative defenses of memory and identity. Noteworthy identify and modify her primitive intrapsychic defenses is the fact that as soon as the somatoform dissociation and dysfunctional family dynamics. In my opinion, an terminated, the other immediately surfaced. This clearly effective therapeutic approach in this case should be indicates that her dissociative defenses were directed toward the development of more problem-solving metamorphosed from the somatic to the psychological coping behaviors, a reduction of her avoidance and dissociative coping style, more efficient communication In the second place, the case of Isabel resurrects the skills and systemic family therapy. These interventions issue of symptom substitution. By this I mean that, in some could allow her to be more expressive of her needs, of her cases, the patient’s symptoms are metaphorical defenses.
preferences and to negotiate with her parents a new If the symptom is treated in a forceful way, without democratic decision-making approach that would permit a clarifying its function for the individual, then it can be more flexible family system. Unfortunately, as far as I know, substituted for another. I think that this case exemplifies the treatment approaches of her psychiatrists have been such a possibility. When the neurologist closed the door pharmacological together with a type of non-specific of his office, and in an hypnotic state suggested that Isabel References
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Alfonso Martínez-Taboas. Profesor at Universidad Carlos Albizu, San Juan, Puerto Rico, Ph.D. in clinical
psychology from the University of Puerto Rico.

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